Duplicated inferior vena cava - a throwback to embryologic atavism

Research Article | DOI: https://doi.org/10.31579/2690-1897/076

Duplicated inferior vena cava - a throwback to embryologic atavism

  • Nandhija Devi J 1
  • Meyyappan M 2
  • Muthiah B 2
  • Rekha A 2*
  • 1 CRRI,Saveetha Medical College,SIMATS,
  • 2 CRRI,Saveetha Medical College,SIMATS,

*Corresponding Author: A.Rekha, Saveetha Medical College, Saveetha Institute of Medical and Technical sciences (SIMATS)

Citation: Devi N, Meyyappan J, Muthiah M, Rekha B. (2021) Duplicated inferior vena cava - a throwback to embryologic atavism. J. Surg Case Repo and Imag. 4(4); DOI:10.31579/2690-1897/076

Copyright: © 2021 A.Rekha, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Received: 22 April 2021 | Accepted: 03 May 2021 | Published: 22 May 2021

Keywords: inferior vena cava; embryologic atavism

Abstract

Duplication of the inferior vena cava( IVC) is only rarely reported and often detected as an incidental finding(0.5-3%). In our patient, the anomolous vessel is the continuation of left iliac vein crossing anterior to the aorta, joining the right IVC at the level of inferior border of L1 vertebra.The association with a prothrombotic state,was exacerbated after splenectomy for this patient who had sickle cell anemia.

Introduction

The inferior vena cava is the channel that drains blood from the lower extremities and the abdominal viscera. Its development entails the contribution from the right sub cardinal vein, right supracardinal vein ,right vitelline vein and rightposterior cardinal veins and the anastomoses between these.[1]. Disruption in the regression of their similar counter parts on the left will contribute to a venous anomaly-ivc duplication. The anomalous presentations with respect to ivc may be varied like duplication, agenesis,left sided IVC , continuation with azygos ,hemiazygos.[3,4].

Case report

A 19 year old boy came to the OPD with complaints of tiredness, diffuse abdominal pain and an episode of fever over a period of 15 days. He gave no history of leg swelling, dyspnoea or palpitations .Clinical examination showed him to anemic and he had a minimal hepatomegaly and a moderate splenomegaly. Routine investigations revealed a Hb of 5.4gm/dl and the peripheral smear delineated microcytic hypochromic RBCs with anisocytosis, few target cell and few sickle cells. The sickling test with sodium metabisulphate corroborated the diagnosis. The confirmation of sickle cell disease (homozygous alleles) was through HPLC.CECT of the abdomen done showed a splenic infarct in an enlarged spleen and minimal hepatomegaly. THE CECT identified the duplication of the IVC,where the left iliac vein continued as the duplicated IVC (Type 2A). 

Figure.1-Contrast enhanced CT: coronal view

 

Figure.2-Contrast enhanced CT:axial view

 

(Fig.1,Fig.2) In our patient there was both right and left IVC and a preaortic segment measuring 1.68 cm,1.57 cm and 0.47cm in diameter respectively.There was no interilliac communication between the vessels and hence it was category 2a.In view of the splenic infract ,with a background of hypersplenism, patient underwent splenectomy after pre op immunisation with polyvalent vaccine .
The prolonged immobilisation  following surgery  his sickle cell status and post splenectomythrombocytosis (5.2lakhs percubic mm) compounded the prothrombotic state that co exists in patients with venous duplication anomalies.He was refered to the vascular department and low dose aspirin was started to prevent venous thrombo embolism.He is well at the 2 month follow up visit.
Discussion
Amongst the various misdirected development involving the IVC, the duplicated IVC is the commonest with an estimated occurrence of about 0.5-3%[1,].This aberrant development happens around 5th to the 8th week of gestation when the three veins common cardinal vein, the vitelline vein and the umbilical vein on both sides form the capacitance system of the body. The cranial part of the IVC is formed from the right proximal vitelline vein, the rest of the IVC entails contribution from the right sub cardinal, right supra cardinal,the anastomoses between them and the right posterior cardinal vein.[2]. There is no contribution from the left sided system .In essence , the subcardinal vein develops first  draining the body wall ,taking over this function from posterior cardinal veins. This involves development of anastomosis channels between the two and is followed by an orderly regression (Fig.3).

Figure.3-Development of inferior venocav

Regression of mostly the anastomotic channel between the two followed later by the posterior cardinal vein. forms the  picture of the supra renal portion of IVC .Later on the supra-cardinal veins form relentless anastomosis with posterior cardinal veins ,subcardinal veins and with its counterpart on the left.this later would form the infrarenal system and takes over the function of draining the lower half of the body.[3]
The channels on the left mostly regress, with the last to regress being the left supracardinalvein. Persistence of this left supra cardinal vein leads to a duplicated venous system (Fig.4).

Figure.4-Anomalous development of inferior venocava

 

Few speculate that the left infrarenal vessels coalesce  with the  right as opposed to the proposed regression .The Genito urinary systems develops in close association with these vessels in the abdominopelvic region ,the vessels anomalous development deranges their development  as well And thus we see associated anomalies like retrocaval ureter, horseshoe kidney. The incidences in various reported age group and gender becomes a very subjective finding for its observance is only incidental but as reported by a study by Morita [4],there is higher incidence of this anomaly in males than in females
There have been studies detailing a classification system for these venous anomalies.The largest study conducted for such classification by Morita had picked up 28 cases with a duplicated IVC. Based on the patterns observed for duplicated IVC alone there was a proposal of 4 types.the study defined an interilliac vein  for this classification purpose -the vein that connects iliac veins be it common ,internal or external iliac vein to the ivc on the contralateral side.[4]

The classification :(Fig.5)

Figure.5-Morita’s classification of pelvic venous anomalies

 

2a -ivc duplication with no inter illiac communication ,2b-ivc duplication with inter illiac vein arising from left common illiac vein,2c -ivc duplication with interilliac vein arising from right common iliac vein,2d-ivc duplication with interilliac vein arising from left internal illiacvein,2e-ivc duplication with inter iliac vein arising from right internal iliac vein.Among all these type 2a was reported to be most common.
The study also observed a left to right ivc diameter ratio to show that in a case with a high ratio the interilliacvein was draining into the left. Thus naturally the left caliber was greater than the right.
The recent classification system to posed by Natsis[5] was based on the vessels caliber
Type 1 - major duplication, where the left and right IVC are of same caliber with that of preaortic segment.
Type 2 - minor duplication where left and right IVC are of same caliber but are both smaller than the preaortic segment.
Type 3- asymmetrical duplication: with either left or right IVC having larger diameter but both being smaller than the preaortic segment.
With vessels anastomosing in front of aorta and the aorta[6] exerting some pressure there is room for stasis and hyper coagulation as suggested by Gayer. IVC malformation is a potential risk factor for thrombus formation as Virchow’s triad is met. Clinically they present with  deep vein thrombosis(DVT)[7,9] or pulmonary embolism .[8].
Duplication of IVC thus complicates IVC filter placement], retro peritoneal surgeries, radical nephrectomy of total renal transplant and testicular malignancy radio imaging. They can be wrongly reported as paraaortic lymphadenopathy, aortic aneurysm or retro peritoneal cyst and can mislead the radiologist and the surgeon [10].
Good preoperative imaging with a CECT or MRI is crucial for the diagnosis [11,12,13,14].
CECT has the disadvantage of radiation exposure but it is still a tool of remark for it helps pick up various other pelvic anomalies like retrocaval ureter, horse shoe kidney[15].MRI  by the non usage of radiation, the clear distinct visualization of tissues has itself pegged for an ideal tool of imaging.
Contrast enhanced 3D MRV has now been accepted as a reference standard for diagnostic visualization of vasculature. It provides a simplified imaging of the venous system without soft tissue superimposition.
In the study by Hofstaetterthe simple fetalultrasonography done (incorporation of high resolution colour Doppler) in during the embryological period (post development of venous system formation-after 8 weeks) could delineate the defect [16,17,18].
Anecdotal reports are available for the management of the prothrombotic states in these patients with anti coagulation,thrombolysis and IVC filters.[19,20,21,22,23]There is no universally agreed position for filter placement in the scenario of asymptomatic IVC .

Conclusion

IVC duplication is often an incidental finding on imaging. It acquires significance as it is a prothrombotic state[24] ,and it can mislead both the radiologist and surgeon. Given that it is uncommon,we n eed to rely on anecdotal reports to plan management strategies. A good preoperative pickup in our patient ( sickle cell anemia undergoing splenectomy), enabled us to start early anticoagulation in the post operative period

References

Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

img

Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

img

Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

img

Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

img

Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

img

Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

img

Sing-yung Wu

Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.

img

Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

img

Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

img

Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

img

Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

img

Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

img

Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

img

Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

img

Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

img

Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

img

Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

img

Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

img

Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

img

Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

img

Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

img

Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

img

Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

img

Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

img

Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

img

S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

img

Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

img

George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

img

Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

img

Khurram Arshad